| NPI | 1306166053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0024167998) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: VA 0024167998) |
| Enumeration Date | 2010-06-04 |
| Last Update Date | 2010-06-04 |